| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
130 |
45 |
$18K |
| D1120 |
Prophylaxis - child |
430 |
224 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
557 |
287 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
408 |
210 |
$8K |
| D0272 |
Bitewings - two radiographic images |
304 |
158 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
41 |
$7K |
| D2140 |
|
101 |
42 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
68 |
32 |
$5K |
| D1110 |
Prophylaxis - adult |
108 |
53 |
$5K |
| D1351 |
Sealant - per tooth |
161 |
32 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
116 |
$4K |
| D1206 |
Topical application of fluoride varnish |
134 |
69 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
91 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
34 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
14 |
$903.40 |
| D0603 |
|
176 |
87 |
$6.68 |
| D0602 |
|
210 |
110 |
$2.02 |